Client’s name: V.T.

Date of referral: 01/23/20

Date of report: 03/06/20
Date of birth: 6/18/80
Primary diagnosis: Traumatic Brain Injury
Precautions/contraindications: Limited cervical ROM secondary to whiplash
Reason for referral to OT: Deficits in short term memory, planning/organizational skills, and
sleep hygiene, and inconsistent functioning
Therapist: Eva Fish, OTS and Corinne Buffo, OTS

S: Client stated “I haven’t had my vestibular stuff interfere with daily activity in a long time.”

O: The client was seen in occupational therapy for 60 minutes, 1x/week, for 8 weeks. His
vestibular symptoms were addressed using repetitive functional activities, such as cleaning
tasks, in addition to a home exercise program. Therapy sessions maintained a focus on
cognitive strategies for planning and organization, as this was a primary goal of the clients.
Goals of utilizing public transit and incorporating a bedtime routine into daily schedules were
also addressed in therapy. Continuity of skills worked on in therapy was promoted using a HEP
and weekly homework assignments, made in collaboration with the client.

PDT: Client completed the Professional Development Tool (PDT) a measure to assess the
client’s satisfaction with treatment. He reported feeling ‘very much’ satisfied with progress made
in therapy and how it relates to his daily living tasks, and he experienced increased
independence as a result. The client reported having a very positive experience in occupational
therapy.

COPM: Client completed the COPM, a semi-structured interview identifying client priorities and
perceived performance and satisfaction of current occupations during initial evaluation (pre) and
again during discharge planning (post). The following scores were provided:

OCCUPATIONAL IMPORTANCE PERFORMANCE SATISFACTION

PERFORMANCE
PRIORITIES

Pre Post Pre Post

Sleep and bedtime 8-9 2 6 2 6

routine

Planning/scheduling 7 5 7 7-8 8

Coordination 6 5-6 7 3 8
(vestibular)

Use of public transit 6 0 7 5 10

Cleaning schedule
Goals
LTG1: Within 6 weeks, the
client will effectively and
independently utilize
cognitive strategies to plan
and execute a weekly
schedule.
STG1.1: Within 2 weeks,
client will independently use
public transit to access
desired areas in the
community, 4 times per week.
STG1.2: Within 4 weeks,
client will independently
prepare for sleep by 11 PM
through the use of a bedtime
routine and proper sleep
hygiene.
LTG2: Within 6 weeks, client
will independently report
missing 1 or less scheduled
daily tasks as a result of
improved vestibular
symptoms.
STG2.1: Within 2 weeks,
client will report having one
or less weekly disturbances to
occupational performance due
to incorporating vestibular
home exercises 1x/day.
STG2.2: Within 4 weeks,
client will complete dynamic
5 7-8 5-6
Initial Performance
- Client often did not plan
ahead for his week, missed
tasks, and felt as though he
was letting tasks pile up until
the last minute and
procrastinating
- Client did not use public
transit and was unaware of
how to navigate public transit
apps and schedules
- Client typically fell asleep
around 1 or 2 in the morning,
and woke up throughout the
night, getting on his phone
when this occurred. Client
was hesitant to wear his
CPAP machine and often
scrolled on his phone before
bedtime.
- Symptoms occasionally
prevented client from going
out in the community and
working. No strategies to
prevent symptoms were
known.
- No vestibular exercise were
known; symptoms
occasionally prevented client
from accessing the
community
- Any task involving moderate
to large head movements
5 7
Ending Performance
-Client is able to plan ahead
effectively and use a daily
and weekly schedule to more
efficiently manage his time
-He uses transit about
1x/week to get to SLC, but
feels comfortable navigating
public transit to get where he
needs and feels successful
with his use of it
-He has made progress with
this goal, saying he follows
his bedtime routine 60-70%
of the time.
-Client reports that he no
longer has vestibular
symptoms interfering with his
daily tasks.
-Client is now incorporating
vestibular exercises into daily
routine, performing exercises
nearly every day
-Vestibular symptoms not
interfering with cleaning
 cleaning tasks with 1 or less stimulated symptoms tasks.
reported vestibular symptoms.

A: The client made good progress in therapy. He achieved LTG1 and LTG2 and made
significant progress towards all STGs, if not achieving them completely. He has demonstrated
high motivation to participate in therapy and incorporate skills learned into his daily life between
sessions. His ability to complete a bedtime routine has steadily increased throughout therapy,
as well as repetitions of vestibular exercises as part of his HEP. He demonstrates the ability to
plan tasks ahead, utilizes cognitive strategies effectively, and is actively participating in
meaningful occupations. He reports increased performance and satisfaction in all goal areas
identified on the COPM, with the exception of performance in his cleaning schedule. This could
be due to personal circumstances interfering with his ability to clean on a regular basis. Overall,
he has made significant progress over the course of 6 weeks.

P: The client will continue to utilize cognitive strategies learned in occupational therapy. To
promote continuity, he will continue to fill out a nightly bedtime routine checklist, daily vestibular
exercises, and utilize a daily planner to organize necessary tasks for the week. The client was
provided with information about vestibular therapy at the University of Utah if he feels he might
benefit from such in the future.

Signature: Eva Fish, OTS Date: 03/06/20